Disparities in Respiratory Care: Medical Center Vs Communi ty Michael Bocci, BS, RRT, RCP Manager of Respiratory Care Services Houston Methodist Hospital Respiratory Care Services
Disclosures No disclosures to report Respiratory Care Services
Learning Objectives • 1. Describe indications and applications of Advanced Ventilator Techniques Used in Trauma and Medical Center Hospitals that are not commonly used in community hospitals. • 2. Describe Respiratory Diagnostic Techniques and Treatment Modalities used in Trauma and Medical Center hospitals not commonly used in community hospitals. Respiratory Care Services
Definitions What is a community hospital? • A hospital is put into one of the community hospital groupings if it is not classified as a teaching hospital — meaning it does not have an intern- and resident-per-bed ratio of at least 0.03 or involvement in at least three GME programs overall. • Broader definition of what a community hospital is goes beyond bed size and teaching status and into various factors, including location, governance structure, the role it plays in a town's economy and the role it plays in increasing care access, among others. Respiratory Care Services
Definitions Continued What is a medical center? • Managed care -a health care organization defined by Structure–a physical plant–e.g., a hospital and buildings in which health care, research, staff support, and ancillary services are provided. • Function–medical services that may be more complex than that provided by a traditional community hospital. Respiratory Care Services
Total Number of All U.S. Registered * Hospitals 5,627 Number of U.S. Community ** Hospitals 4,926 Number of Nongovernment Not-for- 2,870 Profit Community Hospitals Number of Investor-Owned (For-Profit) 1,053 Community Hospitals Number of State and Local Government 1,003 Community Hospitals Number of Federal Government Hospitals 213 Number of Nonfederal Psychiatric Hospitals 403 Number of Nonfederal Long Term Care 75 Hospitals Number of Hospital Units of Institutions 10 (Prison Hospitals, College Infirmaries, Etc.) Number of Rural Community** Hospitals 1,855 Number of Urban Community** Hospitals 3,071 Respiratory Care Services
Texas Medical Center (TMC) Respiratory Care Services
TMC Facts • The Texas Medical Center is the largest medical center in the world with one of the highest densities of clinical facilities for patient care, basic science, and translational research. • The center contains 50 medicine-related institutions, including 21 hospitals and two specialty institutions, two medical schools, six nursing schools, and schools of dentistry, public health, pharmacy and other health- related practices. • All 50 institutions are not for profit. Respiratory Care Services
So what does this all mean? Resources that are available to the patient!!!!!! • The center is where one of the first and largest air ambulance services was created and where a successful inter-institutional transplant program was developed. More heart surgeries are performed at the Texas Medical Center than anywhere else in the world. Respiratory Care Services
Our Perceptions as Clinicians • Community hospital workers as applicants for employment at TMC-differences noted in experiences and skill levels. • Number of hospital beds are less in community hospitals. • Acuity of patients is evaluated for possible transfer to TMC. • Resources available for specialized care-abundant TMC. • Physicians and other professionals coming to TMC as it is a progressive learning environment. Respiratory Care Services
Hospital Systems • Memorial Hermann, CHI-St. Luke’s and Houston Methodist Systems ALL have outlying hospitals that may be considered community hospitals. • Patients can shop around for a hospital that may serve their purposes and not have to travel to the Medical Center. Respiratory Care Services
Community Hospitals • Typically, a community hospital is located in a smaller town, away from a large metropolitan area. A big city can have community hospitals in it, but they have to serve a market segment distinct from a major tertiary care center. • The AHA breaks down its definition of community hospital into two groups: rural community hospitals, with a count of 1,971, and urban community hospitals, which clock in at 3,003. • A community hospital is a place where care can come to a patient, instead of forcing a patient to drive far away for care . Respiratory Care Services
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Clinicians • Applicants from other hospitals • Skill levels • Experiences • Desire to learn and develop Respiratory Care Services
Human Resources Community Hospital Medical Center Respiratory Care Services
Teaching Hospitals Train Tomorrow’s Doctors The work of teaching hospitals is more important than ever, as our nation faces a growing shortage of physicians: • By 2025, the U.S. will face a shortage of between 61,700 and 94,700 physicians in all specialties. • The U.S. population will grow by 27 million people by 2025. • By 2025, the number of Americans over age 65 will increase by 41 percent. Respiratory Care Services
Teaching Hospitals Provide Cutting Edge Care • AAMC teaching hospital members provide around-the- clock, onsite, and fully staffed standby services for critically ill or injured patients. • A significant number of patients are transferred to these hospitals because their illnesses or injuries require a sophisticated level of technology and expertise not available elsewhere in the community. . Respiratory Care Services
Specialized Care ECMO Organ Transplant Respiratory Care Services
Respiratory Care • The conventional modes of mechanical ventilation are primarily used in community hospitals. • Modes such as Assist-Control, SIMV and Pressure Support are dominant. • In The Medical Center, modes such as BiLevel, DuoPAP, BiPhasic, APRV and Adaptive Support Ventilation (ASV) are most frequently seen in addition to the conventional modes. • These modes require advanced skill levels of Physicians and RTs though they are misused as “last resort” modes of ventilation. Respiratory Care Services
Conventional Modes of Mechanical Ventilation SIMV Pressure Support Respiratory Care Services
Nonconventional Modes of Mechanical Ventilation BiLevel APRV Respiratory Care Services
Setting of PEEP • Therapists in community hospitals tend to utilize simpler less complex methods of setting PEEP. • The use of PEEP/Compliance grids and tables is common. • Slow volume pressure volume loops are also commonly seen in community hospitals. • In the Medical Center, the added utilities and features on the ventilators are used such as the PV Tool Pro on the Hamilton vents. Respiratory Care Services
Community Hospital Methods Pressure Volume Loop PEEP Grid Respiratory Care Services
Medical Center Method PV Tool Pro Respiratory Care Services
Weaning Patients from the Ventilator • Many times in the community hospitals, a gradual reduction in ventilatory support is seen over the course of several days or even weeks. • For example, in SIMV a decrease in the rate of 2 per day and then going to pressure support ventilation is almost routine or standard. • In The Medical Center, the use of Adaptive Support Ventilation or similar advanced modes is now commonly utilized. Respiratory Care Services
Adaptive Support Ventilation Respiratory Care Services
Spontaneous Awakening and Spontaneous Breathing Trials Respiratory Care Services
Spontaneous Awakening and Spontaneous Breathing Trails Respiratory Care Services
Ventilator Status Bar Respiratory Care Services
Diagnostic Devices and Procedure s Arterial Blood Gases Capnography Respiratory Care Services
EtCO2 versus Arterial CO2 Respiratory Care Services
Diagnostic Devices and Procedures Mini BAL Sputum Samples Respiratory Care Services
Respiratory Council • For the Houston Methodist System, a Respiratory Council has been developed and its main purposes are communication and also to develop standards of treatments, devices, staff competencies and job descriptions which affords consistency throughout the hospital network. • Hopefully, this may narrow the gap in the services provided from 1 entity community hospital to another. Respiratory Care Services
Conclusion • There are disparities in the treatment and specialized care for the patient when you compare community hospitals and the medical center. • Maybe we can decrease these differences as time goes on. Respiratory Care Services
Learning Assessment Question #1 • Question 1: 1. The advanced modes of mechanical ventilation such as DuoPAP or Bi-level should only be used when a patient’s status is classified as highly critical and a rescue mode is deemed appropriate? Question: True or False? Respiratory Care Services
Question #1 Answer: • The answer is false. • These modes of mechanical ventilation can be utilized throughout a patient’s stay on the ventilator. These modes promote spontaneous breathing and less sedation. Can be used on patients ranging from routine needs for mechanical ventilation to patients with ARDS or on ECMO. Respiratory Care Services
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